Dissociative identity disorder is a rare chronic mental disorder. It is also known as multiple personality disorder. Those affected unintentionally adopt several personality states with different identities. These personalities repeatedly take control of the affected person's behavior.
Here you will find further information as well as selected specialists and centers for dissociative identity disorders.
Dissociative identity disorder (DIS) is the most serious form of dissociative disorder. It is also known as "multiple personality disorder". The disorder contains all the significant elements of other dissociative disorders. The disorder can include, for example
occur.
In dissociative identity disorder (formerly multiple personality disorder), two or more identities exist in the same person @ von Lieres /AdobeStock
Dissociative identity disorder is a chronic disorder. Normally, the dissociative disorders described in the DSM-IV and ICD-10 disease classification systems are temporary. If a dissociative identity disorder is not treated properly, it can become permanent. It can manifest itself in different forms over the course of a person's life.
Multiple personality disorder is one of the most unusual psychological conditions. The person affected splits into several seemingly separate and independent subpersonalities. They alternately determine a person's behavior. This has a tremendously fascinating effect on some people and causes others to express vehement indignation.
The possibility of the existence of such subpersonalities within an individual raises doubts as to whether the generally accepted basic assumptions about the unity of personality and the structure of consciousness are valid.
In addition, almost all symptoms that characterize many other psychiatric disorders can occur. The classification of psychopathological syndromes and comorbid (additionally occurring mental) disorders can therefore be very difficult.
In dissociative identity disorder, a person's ego splits into different personalities, which then all lead a life of their own @ Lazy_Bear /AdobeStock
The history of dissociative identity disorder runs parallel to the history of modern psychiatry.
Jean-Martin Charcot (1825-1893) and his famous collaborators, such as
researched the phenomenon intensively. They made dissociative phenomena in general and the "multiple personality disorder" in particular a central point of their theories on psychopathology and the psyche.
A similar development took place in the USA. The most important representatives, William James (1842-1910) and Morton Prince (1854-1929), had personal experience with DIS patients. On the basis of these experiences, they examined the nature of consciousness and the organization of the psyche.
Even Freud explored the nature of double consciousness at the beginning of his work (e.g. the case of Anna O. in Breuer). Later, however, Freud developed his psychodynamic theory. In short, it does not focus on dissociation, but on repression and other unconscious mechanisms,
Pierre Janet coined the term dissociation as the disintegration and fragmentation of consciousness. He described a diathesis-stress model that is still valid today. It serves as the basis for current theories of dissociation, such as the theory of structural dissociation.
The diagnosis of dissociative identity disorder was first included in a psychiatric classification system in 1980 (DSM-III, APA 1980). It was also included in the ICD-10 in 1991.
In the ICD-10, dissociative identity disorder is listed as a rare disorder. However, its frequency is similar to that of borderline personality disorder. According to estimates, 1-3 percent of the total population is affected. Among patients undergoing psychiatric treatment, 5 percent may be affected by dissociative identity disorder. Dissociative identity disorder is therefore by no means rare.
Women appear to be affected by dissociative identity disorder much more frequently than men.
However, patients are rarely diagnosed or not diagnosed at all, but often misdiagnosed. This means that doctors do not recognize the disorder or make an incorrect diagnosis. However, this probably also applies to all other dissociative disorders. As a result, patients often do not receive psychotherapeutic treatment or do not benefit from the treatment as expected.
Early diagnosis, on the other hand, means that disorder-specific psychotherapy can be initiated. This can have a positive influence on the course of the dissociative identity disorder.
Various studies have attempted to find out why some people suffer from dissociative identity disorder. This has revealed significant physiological differences between DIS patients and control subjects. These differences are expressed in a variety of behaviors.
These include, among others
Overall, DIS patients tend to show greater physiological variability between their identities than simulated identities in control subjects. This variability is greater than the kind of reproducible differences found between different individuals.
Recent studies have found significant psychobiological differences between different types of alternate identities in dissociative identity disorder when each identity alternately listened to a trauma script that only one identity subjectively perceived as a "personal" memory. These differences included subjective sensorimotor and emotional responses, psychophysiological responses such as pulse and blood pressure, as well as patterns of regional cerebral blood flow. This can be measured using positron emission tomography.
These psychobiological differences were not observed when each of the two different types of alternate identities alternately listened to a neutral, non-traumatic, autobiographical memory script.
There is also the hypothesis that alternate identities arise from traumatic childhood experiences. Traumatic experiences before the age of five in particular make it difficult for children to develop a unified sense of self. These difficulties often occur in the context of relationship or attachment breakdown. They can be the precursors and precursors of abuse and the development of dissociative processing.
Severe and prolonged traumatic experiences can lead to the development of dissociated, personified behavioral states (i.e. fragmented personality parts) in the child. These then encapsulate traumatic memories that cannot be endured.
and thus mitigate their influence on the child's overall development.
A secondary structuring of these delimited behavioral states takes place over a longer period of time through various developmental and symbolic mechanisms and ultimately results in the traits of the specific personality traits. These parts can continue to develop in number, complexity and the feeling of separateness as the child goes through childhood, adolescence and adulthood. Dissociative identity disorder develops during childhood, although cases resulting from trauma in adulthood are rarely reported.
Dissociative identity disorder (multiple personality disorder) often results from severe traumatic experiences in childhood @ New Africa /AdobeStock
The theory of "structural dissociation of personality" as an etiological (causal, reasoning) model is based on the ideas of Janet and attempts to create a unified theory of dissociation that incorporates dissociative identity disorder. This theory assumes that dissociation is the result of a fundamental failure to integrate the personality's systems of ideas and functions. After the personality has been exposed to potentially traumatizing events, it can be transformed from its wholeness into an "apparently normal part of thepersonality" (ANP), responsible for everyday life.The ANP is responsible for everyday functioning and the EPis responsible for defense. Defense here refers to psychobiological functions of survival after life threats such as fight/flight, not the psychodynamic type of defense. It is assumed that chronic traumatization and/or neglect can lead to secondary structural dissociations and the occurrence of additional EPs.
In a nutshell, such etiological models state that dissociative identity disorder does not arise from a unitary "core personality" that is fractured or violated. Rather, dissociative identity disorder is the result of a failure of normal developmental integration triggered by overwhelming experiences and disrupted caregiver-child interactions (neglect and lack of responsiveness included) during early developmental periods. This, in turn, leads to some children developing relatively discrete, personalized behavioral states that eventually become DIS personality traits.
Some authors believe that dissociative identity disorder is created by psychologists who believe strongly in the disorder and who implicitly influence their patients to "act out" the symptoms. According to this "sociocognitive" model, dissociative identity disorder is "a socially constructed condition that consists of cues from the psychologist (e.g., suggestive questions about the existence of possible alternate identities), media influence (e.g., film and television portrayals), and the patient's own beliefs about the disorder.(e.g., film and television portrayals of dissociative identity disorder), and broader sociocultural expectations about the assumed clinical features of dissociative identity disorder.
Some proponents of the sociocognitive model, for example, believe that the release of the book and film Sybil in the 1970s played a fundamental role in the development of conceptions of dissociative identity disorder in the minds of the general population and psychotherapists."
Despite these arguments, there are no studies showing that the complex phenomenology of dissociative identity disorder can be induced by suggestion, contagion or hypnosis, or even maintained over long periods of time.
While the American Psychiatric Association and the World Health Organization have characterized dissociative disorders, they have not fully described the characteristics of dissociation as such. Consequently, the DSM-IV-TR states that "the defining feature of dissociative disorders is a disruption of the normally integrated functions of consciousness, memory, identity, or perception".
There is ongoing debate about how broad or narrow the definition of dissociation should be. Putnam (2003) described the dissociation process as "a normal process that initially serves to protect an individual to cope with traumatizing experiences, but then evolves into a dysfunctional or pathological process". A number of authors use the term descriptively to refer to failures in the integration of information and self-attributions that should normally be integrated, and to refer to changes in consciousness characterized by a sense of dissociation from the self and/or the environment.
A further subdivision is based on Pierre Janet's distinction between negative dissociative (i.e. a decrease or abolition of a psychological process) and positive dissociative (i.e. a creation or exaggeration of a psychological process) symptoms. Dell and O'Neil's (2009) definition elaborates the DSM-IV-TR's central concept of disruption: "Pathological dissociation essentially manifests as a partial or complete disruption of a person's integration of psychological processes.
Specifically, dissociation can disrupt a person's awareness and experience of the body, the world, the self, the mind, agency, intentionality, thinking, beliefs, and behavior.thinking, believing, knowing, recognizing, remembering, feeling, willing, speaking, acting, seeing, hearing, smelling, tasting, touching, and so on, in unexpected ways. These interruptions are typically experienced by the affected person as an alarming, autonomic intrusion into their usual responses or functioning. The most common dissociative intrusions include hearing voices, depersonalization, derealization of "made" thoughts, urges, desires, emotions and actions."
Dissociative processes show different manifestations, many of which are not pathological. In particular, Dell (2009) has argued that spontaneous, survival-related dissociation is part of a normal, evolutionarily selected, specific response. This type of dissociation is automatic and reflexive and part of a brief, temporary, normal biological response that disappears once the danger has passed. The relationship between this dissociative response and the strength and nature of the dissociation seen in dissociative disorders is not yet well understood.
It is estimated that 1-3 percent of the total population is affected @ Natalia Klenova /AdobeStock
The difficulties in diagnosing dissociative identity disorder lie primarily in inadequate training on the topics of dissociation, dissociative disorders and the consequences of psychological trauma, as well as sometimes in the bias of clinicians. This results in a certain clinical skepticism as well as misconceptions regarding the clinical presentation.
Although dissociative identity disorder is a relatively common disorder, Kluft (2009) observed that "only 6 percent of those affected make their dissociative identity disorder overtly apparent on an ongoing basis". Rather than displaying obviously different alternate identities, typical DIS patients present a polysymptomatic picture of dissociative and other trauma sequelae symptoms embedded in a matrix of ostensibly non-trauma related symptoms (e.g. depressive symptoms, anxiety symptoms, substance dependence symptoms, somatoform symptoms or eating disorder symptoms etc.). The familiarity of the latter, very familiar symptoms often leads to only these comorbid (additionally occurring) syndromes being diagnosed as a disorder.
Unfortunately, standard diagnostic interviews and methods for assessing psychopathology often do not include questions about dissociative and post-traumatic symptoms or the history of previous psychological trauma. Since DIS patients rarely volunteer information about dissociative symptoms, the lack of specific questions about dissociative symptoms prevents a correct diagnosis of dissociative identity disorder.
The basic prerequisite for the diagnosis of dissociative identity disorder is therefore the active questioning of dissociative symptoms by the practitioner. Where necessary, the free clinical interview should be supplemented by screening questionnaires and structured interviews that investigate the presence or absence of dissociative symptoms and dissociative disorders.
With screening instruments (questionnaires), it should be noted that high scores alone are not sufficient for the diagnosis of a dissociative disorder. This requires further differential diagnostic clarification of the symptoms present in a clinical interview and by means of specific diagnostic instruments such as structured interviews. In practical work, the screening instruments can be used both to clarify the type and extent of the dissociative symptoms and as a way of talking to a person about their experience using specific questions.
The most frequently used screening instrument is probably the questionnaire on dissociative symptoms. The FDS is the German adaptation of the Dissociative Experiences Scale. In the German version, the DES was expanded to include the symptoms of somatic dissociation. It covers both psychological and parts of somatoform dissociation. The FDS has 44 items and takes about 20 minutes to complete.
On a scale of 0 to 100 percent, respondents indicate how often they are familiar with the given examples of dissociative experiences from everyday life. The items are assigned to the subscales absorption, derealization/depersonalization, amnesia and conversion. The FDS is evaluated by averaging. Clinically relevant are total values (total mean values) above 12 as an indication of mild dissociative symptoms; if total values exceed 25, the presence of a dissociative disorder should be suspected by means of a structured interview.
The structured clinical interview for dissociative disorders according to the DSM is the gold standard for the German-speaking world. The SKID-D enables the diagnosis of all dissociative disorders listed in the DSM-IV on the basis of operationalized criteria.
The 277 items of the semi-structured interview provide a differentiated assessment of the type and severity of the dissociative core symptoms of amnesia, depersonalization, derealization, identity uncertainty and identity change. In addition to the respondents' answers, the evaluation also includes dissociative symptoms observed directly during contact, such as amnesia for previous questions, stuporous states, conspicuous changes in behavior and other non-verbal abnormalities from the interview situation.
The Diagnostic and Statistical Manual, 4th edition, text revision (Saß et al. 2003) lists the following diagnostic criteria for dissociative identity disorder (300.14; p.214):
Unfortunately, the description of the disorder in ICD-10 under F44.81 differs strikingly from this criteria-based classification. It summarizes a collection of descriptions and assumptions that only partially correspond to the information in the DSM-IV and contradict scientific literature, e.g. for example, that "the disorder is rare and the extent to which it is iatrogenic or culturally specific is controversial" or that "later changes are often limited to dramatic or stressful events or occur in therapy sessions in which the therapist uses hypnosis or techniques to relax or to calm down".
In recent years, a discussion about the DSM-IV diagnostic criteria for dissociative identity disorder has unfolded.
Dell (2009) has suggested that the level of abstraction of the current diagnostic criteria and corresponding lack of concrete clinical symptoms greatly reduces their usefulness for the non-specialized clinician, and that a compilation of commonly occurring dissociative signs and symptoms would better capture the typical presentation of DIS patients. Others claim that the current criteria are sufficient. Still others suggest reconceptualizing dissociative disorders as belonging to a spectrum of trauma sequelae disorders, thus emphasizing their association with overwhelming and traumatic situations).
Dissociative identity disorder is treated psychotherapeutically. The first step is to establish a trusting therapeutic relationship, which serves to establish basic assumptions of safety, meaningfulness and appreciation, to promote affect differentiation and regulation and to develop self-responsibility, self-efficacy and self-control. This results in a method-integrated, individual long-term psychotherapy that is intended to resolve the original trauma of the affected person and thus create a unified self.
.jpg "Psychotherapie bei dissoziativer Identitätsstörung")
Psychotherapy is usually the first choice fordissociative identity disorder @ Photographee.eu /AdobeStock
The updated treatment guidelines of the ISSTD (International Society for the Study of Trauma and Dissociation 2011), which are currently being translated into German, recommend an eclectic treatment approach that includes psychodynamic, cognitive-behavioral, hypnotherapeutic and trauma-adapted procedures. As with other trauma-related disorders, a phase-oriented approach has proven successful, in which the patient's safety and sufficient stability are sought first, in order to then turn specifically to the processing of traumatic material. In addition, disorder-specific techniques are used that aim to actively incorporate the dissociated self-states into the therapy in order to initiate and support an integration process for the development of a coherent self.
Individual long-term outpatient psychotherapy of up to two hours per week over several years is considered the treatment of choice, but combined therapy offers of outpatient and inpatient interval therapy have also proven clinically successful. There is also positive experience of structured group offers for targeted stabilization in combination with individual therapy, which may be more efficient and economical alternatives to long-term psychotherapy alone. Brand and colleagues (2009) provide a good overview of the available treatment studies in this context.
In the treatment of dissociative identity disorder, medication only plays a role in the treatment of concomitant disorders. If comorbid disorders occur, these must be treated in accordance with the relevant guidelines for the specific disorder. This also applies to drug treatment. For example, in the treatment of comorbid depressive syndromes, antidepressants are used according to the severity of the symptoms.
The underlying symptoms of dissociative identity disorder cannot currently be treated curatively with medication. Naloxone is occasionally used on a trial basis to interrupt dissociative symptoms, but without lasting success.
